SCHEMA  FOR  THE  CLINICAL 
STUDY  OF  MENTALLY  AND 
1DUCATIONALLY  UNUSUAL 
CHILDREN 


J.   E.   WALLACE  WALLIN,  PH.  D. 

Director-elect  of  the  Psycho-Educat tonal  Clinic  in  tin 
St.  Louis  Public  Schools 


INO  CHAPTER  XIX  OP  THE  MENTAL 
HEALTH  OF  THE  SCHOOL  CHILD 
pp.  429-450 


SIEW  HAVEN:   YALE  UNIVERSITY  PRESS 
MDCCCCXIV 


EX    LIBRIS 
THE    UNIVERSITY 

OF    CALIFORNIA 

— «»«_.  \ 

FROM  THE  FUND 
ESTABLISHED  AT  YALE 

IN  1927  BY 
WILLIAM  H.  CROCKER 

OF  THE  CLASS  OF  1882 

SHEFFIELD  SCIENTIFIC  SCHOOL 

YALE  UNIVERSITY 


A  SCHEMA  FOR  THE  CLINICAL 

STUDY  OF  MENTALLY  AND 

EDUCATIONALLY  UNUSUAL 

CHILDREN 


By 


J.  E.  WALLACE  WALLIN,  PH.  D. 

l« 

Director-elect  of  the  Psycho-Educational  Clinic  in  the 
St.  Louis  Public  Schools 


BEING  CHAPTER  XIX  OF  THE  MENTAL 

HEALTH  OF  THE  SCHOOL  CHILD 

pp.  429-450 


NEW  HAVEN:    YALE  UNIVERSITY  PRESS 
MDCCCCXIV 


A/35 


COPYRIGHT,  1914 

BY 

YALE  UNIVERSITY  PRESS 


A    SCHEMA    FOR    THE    CLINICAL    STUDY    OF 

MENTALLY  AND  EDUCATIONALLY 

UNUSUAL  CHILDREN. 


The  scientific  study  of  the  educatienaily  ^ex^e 
child  should  follow  a  definite  plan  of  procedure  and  should 
be  sufficiently  comprehensive  to  include  an  investigation 
of  all  the  important  intrinsic  and  extrinsic  factors  which 
may  mar  his  development.  A  complete  investigation 
should  include  the  study  of  the  child's  developmental, 
family,  hereditary  and  school  histories,  an  investigation  of 
his  past  and  present  social  and  physical  environment,  and 
an  examination  of  his  present  physical  condition  and 
anthropometric,  educational  and  psychological  status.  A 
completely  satisfying  investigation  thus  requires  the  co- 
operation of  the  social  and  hereditary  worker,  the 
teacher,  the  medical  expert  and  the  psycho-educational 
clinician. 

The  following  schema  is  offered  as  a  guide  to  the  scien- 
tific examination  of  mentally  abnormal  children.  It  may 
be  used  in  either  of  two  ways.  First,  the  various  forms 
may  be  reprinted  on  separate  blanks  with  appropriate 
vacant  spaces,  to  be  filled  in  by  the  investigator.  The 
chief  objection  to  this  plan  is  probably  financial:  blanks 
are  expensive,  and  in  few  cases  will  it  be  possible  to  fill  out 
all  the  spaces,  while  in  many  cases  it  will  not  be  necessary 
to  do  so.  Second,  the  investigator  may  thoroughly 
familiarize  himself  with  the  contents  of  the  various  forms, 


and  follow  them  as  a  systematic  and  comprehensive  guide 
to  his  investigation;  but  instead  of  entering  the  data  on 
printed  blanks  he  may  write  up  a  'running  history,'  giving 
the  essential  facts  of  the  case,  on  blank  sheets.  Whether 
the  one  plan  or  the  other  is  followed,  it  is  desirable  that 
every  investigator  should  append  a  brief  summary  of  his 
findings  and  recommendations. 

"•Jt'}?annat;b;3;  t,6d  forcibly  impressed  upon  social,  field 
.and  lajjpratory  'investigators  of  children  that  parents  and 
•  V0U'tjv.(?g4-r6il -any; frctm., whom  bio-social  data  are  sought — 
must  be  approached  with  much  tact  and  judgment. 
Gathering  hereditary,  personal  and  social  data  is,  at  best, 
a  very  delicate  undertaking,  subject  to  many  errors,  and 
many  investigators  fail  utterly  to  secure,  or  otherwise 
they  pervert,  the  significant  factors,  either  because  they 
do  not  know  how  to  approach  parents  so  as  to  win  their 
confidence  and  put  them  in  a  communicative  attitude,  or 
because  they  suggest  answers  by  their  indiscreet  use  of 
leading  questions.  While,  therefore,  a  'guide'  will  prove 
of  the  greatest  value  to  child  investigators,  they  must 
know  above  all  else  how  to  use  the  guide  with  tact,  common 
sense  and  discriminating  intelligence. 

Social  and  hereditary  investigators  must  also  be 
cautioned  against  drawing  premature  or  unjustifiable 
conclusions  from  hearsay  evidence.  They  must  accustom 
themselves  to  weigh  reports  very  carefully,  and  to  verify 
them  in  every  way  possible.  There  is  a  large  amount  of 
work  done  today  in  heredo-biology,  heredo-psychology  and 
social  investigation  which  is  careless,  unscientific  and 
worthless.  Do  not  conclude  that  someone  was  feeble- 
minded or  insane  simply  because  someone  reported  him 
to  be  'slow,'  'stupid,'  'feebly-gifted'  or  as  acting  'queerly.' 
Do  not  conclude  that  a  child  is  feeble-minded  simply 


because  he  appears  stupid  or  feeble-minded  to  you,  or 
because  he  happens  to  test  three  years,  or  even  four  or  five 
years,  retarded.  Science  cannot  be  founded  on  guess- 
work. Gather  all  possible  facts  bearing  on  your  case, 
and  avoid  hasty  generalizations.  It  is  rather  for  the 
trained  specialist  to  supply  the  diagnoses. 

It  need  scarcely  be  said  that  when  the  same  person 
gathers  the  developmental,  hereditary  and  school  data,  it 
is  not  necessary  to  re-record  on  each  blank  the  identical 
facts  called  for  in  the  different  blanks  unless  there  is  a 
discrepancy  in  the  statements. 

FORM  I 
DEVELOPMENTAL  HISTORY 

No.  Diagnosis  Source  of  data  Date 

Full  name  Age:  date  of  birth 

yrs.  mos.  Address    (with    'phone)  Father's 

name  Mother's  name  Guardian's 

name  By  whom  referred  for  investigation 

(Underscore  appropriate  words,  and  fill  in  other  data) 

CONCEPTIVE  CONDITIONS:  diseases,  syphilis,  gonorrhea,  tuberculosis, 
scrofula,  alcohol,  drugs,  health,  overwork,  starvation,  fright,  accidents, 
anxiety,  excitement,  aversion,  etc.,  before  or  at  time  of  conception  in 
mother 
in  father 

PREGNANCY  CONDITIONS:  above  data  for  mother  during  pregnancy. 
Also  pelvic  diseases,  attempts  at  abortion,  'maternal  impressions,' 
legitimacy  of  child 

BIRTH    CONDITIONS:   premature    (how   much)  full   term, 

weight  labor   normal,   prolonged    (how  long)  or 

difficult;  delivery  with  instruments  or  anesthesia;  difficult  animation, 
breathing  or  crying,  cyanosis;  injury  or  deformity  (especially  of 
head)  or  paralysis;  inability  to  suckle 

GROWTH  CONDITIONS:  nursed  (by  whom,  how  long) 
Bottle  fed  (how  long,  what)  What  fed  when 

weaned  Sickly  as  baby  or  child  First 


teeth,  when  (any  fever  or  illness)  Second  teeth, 

when  Fontanel,  closed  when  First 

crawled,  when  Stood  alone,  when 

Walked   (unsupported  steps),  when  Walked  well, 

when  Ran  well,  when  Supported  head, 

when  Talked — single  words  correctly  applied, 

when  Short  phrases,  when  Complete 

sentences,  when  Specific  speech  defects,  what, 

since  when,  circumstances  Able  to  hold  or  grasp  well, 

when  Control  of  fundamental  reflexes   (acquisition 

of  tidy  habits),  when  Beginning  of  puberty 

Of  menstruation  (difficult) 

DISEASES  AND  ACCIDENTS  (age,  attributed  cause,  severity,  subsequent 
effects,  recovery) :  measles,  smallpox,  whooping  cough,  scarlatina, 
scarlet  fever,  mumps,  diphtheria,  cerebro-spinal  meningitis,  infantile 
paralysis,  rickets,  malnutrition,  inanition,  scrofula,  swollen  glands, 
adenoids,  enlarged  tonsils,  nose,  eyes,  ears,  nervousness,  muscular 
twitches,  where  chorea,  periodical  headaches,  fainting 

spells,  convulsions   (infantile  or  epileptic,  with  data) 
enuresis  (nocturnal  or  diurnal),  falls,  injuries,  orthopedic  deformities, 
pubertal  or  menstrual  troubles  Vaccinated,  when, 

effects  Hospital  or  surgical  record 

M.  D.'s  by  whom  examined  or  treated 
Diagnoses  by  different  M.  D.'s 

HABITS:  sleep    (past  and  present) :  hours  of  retiring  and  arising 
sound,   restless,  insomnia    (cause).     Drinking: 

tea,  coffee,  wine,  beer,  whisky;  drugs   (how  much,  how  frequently) 
Appetite:  hearty,  poor,  capricious,  gluttonous,  food 
preferences,  usual  menu  Chews  or  smokes:  cigarettes, 

cigars,  pipe.       Excessive  indulgence  in  sweets  Masturbates, 

sexually  immoral  or  perverse. 

MENTAL  AND  PHYSICAL  PECULIARITIES  IN  INFANCY  AND  CHILDHOOD 
(age  first  observed,  parents'  explanation):  queer  or  bizarre  ideas, 
action,  behavior,  speech,  disposition  Fits  of  crying  or 

laughing,  with  or  without  cause  Outbreaks,  tantrums, 

continuous  or  periodic  Night  terrors,  sleep-walking 

Morbid  fears  Criminal,  intemperate,  immoral  or 

destructive  tendencies  Running  away  Solitude 

or  company  preferred  Shut-in,  solitary  disposition 

Playing  or  seeking  younger  or  older  persons  or  opposite  sex 
Dull,    stupid,    lazy,    indifferent,    bright,    talented,    precocious    (with 
facts) 


RECORD    or    DELINQUENCIES    (with    ascribed    causes,    institutional, 
court  and  probation  records) : 

AGENCIES  which  have  previously  been  interested  in  this  child: 

ADDITIONAL  REMARKS: 

RECOMMENDATIONS  (by  whom) : 

RESULTS  OF  FOLLOWING  RECOMMENDATIONS  (as  reported  later): 

SIGNATURE  : 

FORM  II 
FAMILY  AND  HEREDITARY  HISTORY 

No.  Diagnosis  Source  of  data  Date 

Full  name  Born,  where  Age:  date  of 

birth  yrs.          mos.  Lives  with  at 

(street,  with  'phone)  Name,  with  birthplace,  nationality 

and  religion  of  father  of  mother 

Language  spoken  at  home  Order  of  child's 

birth  no.  of  sisters,  alive  dead  of  brothers, 

alive         dead          Age  of  father  at  child's  birth  of  mother 

Blood   relationship  between  parents  Parents  living 

apart,  together,  divorced.    Occupation  and  weekly  earnings  of  father 

of  mother  of  other  children  of  child 

Health,  morals,  habits,  diseases,  sexual  habits,  etc.,  prior  to  birth  of 
child,  of  father  of  mother  (see  Form  I) 


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FORM  III 
HOME  AND  NEIGHBORHOOD  ENVIRONMENT 

No.  Diagnosis  Source  of  data  Date 

Full  name  Age:  date  of  birth 

yrs.  mos.  Address   (with  'phone)  Lives 

with  Parents'  address,  if  different 

Father's  name  Mother's  name 

Parents  alive  Parents  living  together  If 

separated,  divorced  or  deserted.    Guardian's  name  and  address 

Child's  birthplace  Language  spoken  in 

home  Referred  for  investigation  by 

Successive  places  of  residence    (with  sanitary,  hygienic  and  moral 
conditions  of  each) 

PRESENT  HOME  INFLUENCES 

(Underscore  appropriate  words,  and  fill  in  other  relevant  data) 
FINANCIAL:  rich,  moderate,  poor,  impoverished,  proverty-stricken, 
charity  case.     Weekly  earnings  of  father  mother 

children  Breadwinners,  who  Influence  of  financial 

conditions  on  child's  care 

FOOD:  quantity  quality  DRINKS: 

what  how  often  how  much  No.  of  meals 

(typical  menus) 

CLOTHING:  ample,  insufficient,  shabby,  soiled,  tasteless,  immodest 
(effect  on  child) 

BATHING:  frequency 

HOUSING:  flat,  tenement,  house;  no.  of  rooms  of  bedrooms 

bathroom  no.  of  lodgers  in  family  of  boarders 

Clean,  bright,  sunshiny,  artistic,  attractive,  dark,  dingy,  damp,  filthy, 
disordered,  well  or  poorly  ventilated.     Garbage  Sewerage 

Child's  bedroom:  quiet,  good  ventilation,  light,  sleeping  companions, 
no.  in  room  Hours  of  retiring  and  arising 

HOME  LIFE:  excellent,  tranquil,  religious,  moral,  refined,  upset,  dis- 
turbed, boisterous,  raw,  quarrelsome,  brutal,  fighting,  vulgar,  degrad- 
ing irreligious,  immoral,  bad. 

HOME  TREATMENT:  excellent,  good,  kindly,  good  care,  indifferent, 
neglectful,  poor  care,  parents  away,  petted,  coddled,  well  or  poorly 
disciplined,  ridiculed,  rebuffed,  irritated,  maltreated,  whipped, 
frightened,  abused,  by  father,  mother,  stepmother,  siblings,  guardians, 
etc.  Overworked 


CHILD'S  DEPORTMENT  AT  HOME:  excellent,  good,  average,  poor,  bad; 
obedient,  disobedient;  mischievous,  quarrelsome,  fights,  cruel  to 
animals  or  siblings  or  playmates,  incorrigible,  destructive;  cheats, 
steals,  squanders  money,  pawns,  gambles,  plays  craps,  deceives,  lies, 
untrustworthy;  neat,  careless,  indolent,  immodest,  immoral;  runs 
away.  Attitude  toward  parents,  siblings,  playmates,  strangers 
Toward  reprimands  and  punishment  How  punished 

Deportment  of  siblings  at  home 

AMUSEMENTS  AT  HOME:  what,  cards,  games,  plays,  singing,  music, 
reading,  proper,  improper.  How  does  child  spend  leisure  time? 

Chief  interests  at  home  Vacations, 

when  where   spent 

WORK:  complete  record  of  jobs,  with  dates,  how  long  held,  hours, 
pay,  success,  reasons  for  changes  or  discharge 
Age  on  taking  first  job 

RELIGIOUS  DISPOSITION:  religious,  irreligious  or  indifferent.  Attends 
church,  where,  how  often,  willingly  or  reluctantly 
Attends  Sunday  school,  where,  how  often,  willingly 

NEIGHBORHOOD  INFLUENCES 

PHYSICAL  SURROUNDINGS:  sanitary,  insanitary,  dark,  smoky,  filthy, 
shimmy,  densely  populated,  foreign  population,  saloons,  dance  halls, 
gambling  joints,  picture  shows,  immoral  resorts. 

SOCIAL  ENVIRONMENT:  character  of  chums  or  associates  (boys,  girls, 
adults),  good,  bad,  vulgar,  gamblers,  crap  players,  immoral,  corrupt, 
criminal,  thieves.  Belongs  to  clubs  or  gangs,  as  leader  or  follower,  what 
kind  (social,  amusement,  literary,  predatory,  criminal,  etc.),  effects 
of  on  child  ^  Tendencies  toward  loafing,  vagrancy,  migration. 

Recreation  facilities  of  neighborhood:  playgrounds,  public,  private, 
supervised,  unsupervised,  streets,  home  yard,  athletic  field,  gymnasium, 
social  settlement  house.  Seeks  what  kinds  of  amusements  (games, 
plays,  loafing,  running  around,  ball,  gambling,  crap  playing,  immoral 
practices,  selling  papers,  theaters,  picture  shows,  etc.).  Plays  with 
boys  or  girls,  older  or  younger.  Attends  picture  shows  or  theaters, 
how  often  What  kind  of  shows  preferred 

Effects  of  on  child 

RECOMMENDATIONS  : 

RESULTS  OP  RECOMMENDATIONS  (from  later  investigations) : 

SIGNATURE  : 

10 


FORM  IV 
SCHOOL  HISTORY 

TEACHERS'    REPORTS    ON    PEDAGOGICAL,    PSYCHOLOGICAL,    SOCIAL    AND 
MORAL  TRAITS 

No.  Diagnosis                 Reported  by  (with  position) 

Date  Full  name                                  Sex 

Age:  yrs.  mos.            Birthday                                      Address  (with 

'phone)  Parents'  or  guardian's  name  (and  address, 


if  different  from  child's) 
and  religion  of  father 
Language  spoken  in  child's  home 


Nationality,  language 
mother 
By  whom  referred 


(Underscore  appropriate  words :  once  for  'moderate,*  twice  for  'marked,'  and 
thrice  for  'extreme'  degree.    Also  fill  in  data  in  blank  spaces.) 

ATTENDANCE  RECORD:  Age  on  entering  first  school   (kindergarten 
included) 


Names  of  schools 
attended,  in 
correct  time  order 

Location  of 
School 

Time, 
from     to 

No.  of 

months  in 
attendance 

Grades 
completed 

Grades 
repeated 

(1) 

(2) 

(3) 

(4) 

Repetition:  number  of  months  spent  in  each  grade  child  has  repeated 

Total  time  (years  or  months)  spent 

repeating  work  Retardation:  grade  in  which  child 

should  be  according  to  age  Present  grade 

Amount  of  pedagogical  retardation  (yrs.  and  mos.) 
Attendance,    regular    or    irregular,    during    past    or    present    time 
(ascribed  causes  of  irregularity) 

PAST  RECORD:  character  of  work,  conduct,  disposition,  traits,  etc., 
as  reported  from  previous  teachers  or  specialists 

PRESENT  PEDAGOGICAL  STATUS:  School  efficiency  in  general:  excellent, 
good,  fair,  poor,  very  poor,  total  failure.     Prospects  of  promotion: 
excellent,  good,  fair,  poor,  none.     Poorest  work  in  which  branches 
Best  work  in  which  branches 


11 


Special  aptitudes,  what  Greatest  interests,  or  likes,  in 

school  work  Greatest  dislikes 

Pedagogical  traits  in  which  strongest  In  which 

most  deficient  Learning  capacity:  is  child  good 

or  poor  in  ability  to  observe  to  concentrate 

to  memorize    (mechanically,  logically,  understandingly) 
to  retain  to  express  orally  or  in  writing  to 

form  habits  to  adapt  self  to  new  or  changing  situations, 

conditions  or  emergencies  to  think,  judge,  reason,  under- 

stand to  do  independent  work  to  lead 

to  direct  to  originate,  invent  to  keep  a  level 

head  (easily  confused)  Learns  best  by  repetition,  rote, 

memorizing,  reasoning,  imitation,  reading,  being  told,  doing  or 
experimenting  for  self  (hit  or  miss).  Accomplishments:  in  reading; 
knows  alphabet  (letters  not  known)  reads  in  what 

reader  how  well  reads  at  sight,  syllables,  short 

words,  long  words,  spells  out  words  In  arithmetic : 

counts,  how  far  Ability  in  addition,  subtrac- 

tion multiplication  division 

problems  How  far  advanced  Best  in 

concrete  or  abstract  work  In  spelling:  sample  words 

child  can  spell  Words  child  cannot  spell  In 

writing  In  drawing  In  grammar  In 

language  work  In  speaking,  dramatizing 

In  music  In  kindergarten  In  manual  train- 

ing  In  shop  work  In  domestic  science 

In  school  gardening  In  gymnastics,  games  In 

history  In  geography  Ability  of  brothers 

of  sisters 

Reported  defects  or  capacities  of  mother 
of  father 

ATTITUDE  TOWARD  SCHOOL  WORK:  interested,  willing,  tries,  indus- 
trious, energetic,  cheerful,  trustworthy,  lazy,  slovenly,  careless,  shirk- 
ing, despairing,  diffident,  non-persevering,  easily  wearied  or  fatigued, 
grows  sleepy,  dopey,  disinterested,  bored,  inattentive,  complaining. 

ATTITUDE  TOWARD  CORRECTION,  REPROOF  OR  PUNISHMENT:  heedless, 
resentful,  headstrong,  obstinate,  talks  back,  abusive,  sensitive,  cries, 
indifferent.  Very  responsive,  tries  to  improve,  takes  it  with  good 
grace. 

ATTITUDE  TOWARD  PLAYS  AND  GAMES:  seeks  or  avoids  games.  Plays 
much  or  little.  On  playground  Plays  with  boys  or 

girls  with  younger  or  older  children 

12 


Fond  of  what  games  or  plays  Plays  make-believe 

plays  ability  to  plan  or  lead  games 

Gets  confused  in  games  Loses  self-control 

Behavior  in  games 

MENTAL,  MORAL  AND  SOCIAL  TRAITS:  Circumspect,  deliberate, 
thoughtful,  thoughtless,  impulsive,  careless,  slothful,  slovenly,  lazy, 
inert,  slow,  dull,  stupid,  apathetic,  unresponsive,  taciturn,  reticent, 
diffident,  retiring,  bashful,  quiet 

Bright,  talented,  precocious,  quick,  responsive,  talkative,  loquacious, 
communicative,  entertaining,  boring 

Cheerful,  good-natured,  gay,  humorous,  kind,  affectionate,  sympa- 
thetic, helpful,  generous,  frank,  obedient 

Moody,  sensitive,  despairing,  fretful,  cranky,  resentful,  malignant, 
defiant,  angry,  meddlesome,  complaining,  quarrelsome,  trouble  maker, 
brutal,  fights,  kicks,  scolds,  nags,  spiteful,  jealous,  sullen,  selfish, 
self-centered,  proud,  domineering,  bossy,  changeable  moods,  capricious 
disposition  or  character 

Graceful,  artistic,  neat,  awkward,  clumsy,  poor  gait,  poor  motor 
control,  stumbles,  falls,  injures  self 

Bold,  reckless,  heedless  of  danger,  venturesome,  blustering,  noisy, 
fearsome,  cowardly 

Restless,  fidgety,  nervous,  scowls,  twitching  movements    (of  what) 
excessive  movements,  emotional,   excitable, 
impulsive,  passionate,  violent 
Strange  or  peculiar  actions,  habits,  speech  (what) 
Sudden  or  capricious  outbreaks  of  passion,  anger,  fear,  destructive 
tendencies,   love,    gaiety,    laughing,   crying,    tantrums,    fits,   fainting 
spells.    Automatic  actions  (when  excited  or  otherwise) 
Suspicious,    solitary,    seclusive,    shut-in,    avoids    company,    dreamy, 
observant 

Honest,   truthful,   pure,   modest;   dishonest,   untruthful,   steals,   lies, 
profane,  swears,  obscene,  lewd,  masturbates,  immoral 
Any  sense  of  shame,  of  difference  between  right  and  wrong,  of  guilt, 
remorse,  sorrow,  reverence,  religion 

Speech:  stutters,  stammers,  lisps,  lalls,  indistinct,  inarticulate, 
sluggish,  mumbling,  thick,  incoherent,  halting,  jerky,  rambling,  point- 
less, labored;  clear,  fluent,  logical,  sensible,  braggadocious,  egotistical, 
gossipy;  declaims,  recites,  sings 

Headaches,  eyestrain,  holds  eyes  near  work,  mouth  open,  poor  hearing, 
takes  cold  easily,  running  nose,  gets  sick,  tired 
Smokes,  chews.    Data  from  school  medical  record: 

13 


What  special  measures  have  been  taken  to  overcome  the  child's 
pedagogical  deficiencies  ? 
To  overcome  his  physical  defects 
His  moral  or  social  shortcomings 

RESULTS  or  THESE  MEASURES: 

RECOMMENDATIONS  : 

RESULTS  OF  FOLLOWING  RECOMMENDATIONS   (from  later  inquiries): 

SIGNATURE  : 

FORM  V 
PHYSICAL  AND  ANTHROPOMETRIC  EXAMINATION 

No.  Diagnosis  Examiner  Date 

Full  name  Sex  Birthday 

Age:  yrs.  mos.  Address  Parents'  or 

guardian's  name  (and  address,  if  different,  with  'phone) 

Brought  by  Referred  by 

(Underscore  appropriate  words:  once  for  'moderate,'  twice  for  'marked,'  and 
thrice  for  'extreme'  degree.  Supply  all  relevant  data  in  blank  spaces.) 

DEFECTS,  DISEASES,  DISORDERS  AND  STIGMATA 
(Anatomical,  physiological,  neurological) 

GENERAL  APPEARANCE:   Expression  nutrition 

Fat,  corpulent,  lean,  emaciated,  fair,  normal. 

SKIN:  complexion;  pallid,  sallow,  ashen,  oily,  moist,  dry,  leathery, 
wrinkled,  baggy,  florid,  scars,  birthmarks. 

TEETH:  carious   (number,  degree)  roots,  tartar, 

impacted,  irregular,  malocclusion,  rachitic,  serrated,  pointed,  Hutch- 
inson's  Gums 

TONGUE:  thick,  pointed,  large,  small,  furrowed,  enlarged  papillae. 

THROAT:  tonsils,  enlarged,  atrophied,  submerged,  pitted,  soft, 
removed.  Pharyngitis.  Laryngitis.  Mouth  breather.  Lymph  glands. 
Thyroid,  enlarged,  atrophied.  Adenoids. 

PALATE:  cleft,  V-shaped,  arched,  narrow. 

LIPS:  normal,  hare-lip,  thick,  thin,  everted,  fissured. 

NOSE:  deflected  septum,  enlarged  turbinates,  polipi,  rhinitis,  broad 
base,  sunken  bones,  squat,  mongoloid,  cretinoid. 

EYES:  acuity,  R  L  Astigmatism  Small 

palpebral  fissure,  exophthalmos,  choked  disc,  scotoma,  hemiopsia, 
irregular  or  eccentric  pupils,  ptosis,  oblique  mongolian,  epicanthus. 

14 


Nystagmus,  strabismus,  diplopia,  accommodation  to  light  to 

distance  Argyll-Robertson 

Iris,  color,  R  L  Wearing  proper  or  improper  glasses 

EARS:  acuity,   R  L  Rinn6  Otitis  media, 

R  L  Impacted  cerumen,  perforated  drum,  otorrhea. 

Large,  small,  Darwinian  tubercle,  lobule  absent,  fossae  absent  or  irre- 
gular, pinna  (size,  shape)  asymmetries 

FACE:  immobile,  mobile;  forehead,  Bombe",  receding,  low  or  narrow; 
prognathous  jaws,  asymmetries 

HEAD:  hydrocephalic,  macrocephalic,  microcephalic,  rachitic,  syphi- 
litic, cretinoid,  asymmetries.  Hair:  color  coarse,  dry,  oily, 
scant,  brittle.  Pediculosis. 

SHOULDERS:  round,  square,  stooped,  asymmetrical.    Scaphoid  scapula 

SPIKE:  scoliosis  C          D          L          lordosis,  C          D          L 
kyphosis 

CHEST:  flat,  rachitic,  pigeon,  funnel,  barrel-shaped,  asymmetrical. 
Lungs  Respiration,  rate  character 

UPPER  LIMBS: 

LOWER  LIMBS: 
Flat  foot 

CIRCULATION:  good,  poor.  Heart:  dilation,  murmurs,  displacements. 
Pulse:  volume  rate  rhythm  pressure  Veins 

Arteries  Blood  examination:  red  corpuscles 

white  corpuscles  hemoglobin  color  index 

Widal  Wasserman 

ALIMENTATION:  appetite  digestion  abdomen 

stomach  intestines 

GENITO-URINARY  SYSTEM: 

NEURO-MUSCULAR:  tone,  relaxed,  flabby,  tense.  Corrugation,  over- 
action  of  f rentals.  Tremors,  coarse,  fine,  unilateral,  spastic,  jerky, 
intermittent,  rhythmical,  of  what  parts  Hand  balance: 

relaxed,  tense,  drooping,  asymmetrical,  finger  twitches  Station: 

relaxed,   unsteady.      Head    balance  Gait:    normal,    lively, 

clumsy,  shuffling,  spastic,  ataxic,  waddling.     Paralyses 
Contractures  Fainting  spells  Tics 

Habit  spasm  Convulsions  Chorea 

Epilepsy  Hysteria  Headache,  migraine 

Anesthesias 

Reflexes:   patellar,   R  L  Clonus  Babinski 

Other  reflexes  Defective  speech 

OTHER  DEFECTS  OR  STIGMATA: 

15 


ACTIVE  DISEASE  PROCESSES:  record  the  diseases,  and  indicate  whether 
slight  or  serious,  of  the  integumentary,  skeletal,  muscular,  nervous, 
nutritive,  respiratory,  circulatory,  lymphatic,  excretory  and  repro- 
ductive systems. 

HISTORY  OF  DISEASES,  DEFORMITIES  AND  ACCIDENTS,  WITH  PREVIOUS 
MEDICAL  DIAGNOSES: 

NAME  OF  EXAMINER: 

PHYSICIAN'S  RECOMMENDATIONS: 

RESULTS  OF  RECOMMENDATIONS  (as  later  ascertained) : 
Physician  or  hospital  recommended: 

ANTHROPOMETRIC  MEASUREMENTS 

Weight:  Ibs.  kg.  Stature,  net  standing  (mm.) 

Sitting  Ponderal  index  Statural  index 

Statural  type  Spread  of  arms 

Spirometry:  123  Chest  girth  (below  level  of  axillae): 

maximal  inhalation  exhalation  normal  Vital  index 

Dynamometry:  Rl  2  3  LI  2  3  Head 

measurements:  circumference  height  length  (antero- 

posterior  diameter)  breadth  cephalic  index 

Other  measurements 

FORM  VI 
PSYCHOLOGICAL  EXAMINATION 

It  has  been  deemed  wise  to  omit  a  schema  for  conducting  psycho- 
logical examinations  for  the  following  reasons.  First,  a  considerable 
number  of  graded  scales  for  testing  intelligence  (particularly  versions 
of  the  Binet-Simon  scale)  are  now  easily  accessible  in  English. 
Second,  hundreds  of  different  psychological  tests  and  experiments  are 
equally  accessible  in  the  standard  books  dealing  with  psychological 
tests  (e.g.,  the  manuals  by  Whipple,  Franz,  Titchener,  Sanford, 
Starch,  Scripture).  It  would  be  futile  to  attempt  to  print  a  selected 
list  of  such  tests  here,  because  the  expert  experimental  psychologist 
is  qualified  to  make  his  own  selection,  while  the  inexperienced 
psychologist  (physician,  nurse,  teacher)  would  scarcely  be  able  either 
properly  to  conduct  the  experiments  without  technical  training,  or 
elaborate  explanations,  or  correctly  to  interpret  the  findings.  Third, 
there  is  little  profit  in  outlining  a  comprehensive  series  of  tests  until 
reliable  clinical  norms  are  available.  Unfortunately  such  norms  are 
not  yet  available.  The  fact  that  this  is  so  makes  it  all  the  more 

16 


necessary  that  the  clinical  psycho-educational  examiner  should  possess 
very  extensive  first-hand  experience  with  many  types  of  mentally 
unusual  children,  so  that  he  will  be  able  to  diagnose  cases  fairly 
accurately  with  the  aid  of  a  minimal  number  of  tests. 

FORM  VII 
PEDAGOGICAL  EXAMINATION 

Until  we  have  available  a  series  of  clinical  pedagogical  age-norms, 
in  various  school  studies,  established  by  objective  tests  given  under 
standard  and  controlled  conditions,  possibly  to  individuals  rather 
than  to  groups — such  as  the  Courtis  scores  in  the  fundamental  mathe- 
matical processes,  though  these  are  group  norms — it  would  be  of 
little  avail  to  outline  a  schema  for  the  pedagogical  testing  of  the  child. 
We  have,  to  be  sure,  the  pedagogical  scales  by  Vaney  and  Holmes, 
but  the  former  is  very  limited  in  range  and  not  entirely  appropriate 
to  pupils  trained  by  American  school  methods,  while  the  latter  has 
not  been  experimentally  derived  by  objectively  testing  individual 
children  of  various  ages  (the  method  of  derivation  is  not  revealed). 
It  is  merely  an  abbreviated  course  of  study  for  grades  two  to  five 
which,  it  is  assumed,  represents  the  pedagogical  accomplishments  of 
normal  children.  Until  we  possess  satisfactory  pedagogical  age  scales 
of  development,  it  will  be  necessary  to  use  (but  with  discriminating 
judgment)  the  school  record  of  the  child  (Form  IV). 

FORM  VIII 
SUMMARY  OF  IMPORTANT  FINDINGS 

It  is  very  desirable  that  social  or  field  workers  epitomize  for  the 
busy  examiner  the  chief  findings.  This  blank  should  be  comprehen- 
sive, yet  very  brief:  it  should  contain  only  the  data  which  seem  to 
have  an  important  bearing  on  the  case,  which  are  important  for 
diagnosis  and  prognosis.  It  may  also  include  the  chief  results  of  the 
physical,  anthropometric  and  psychological  examinations,  the  final 
(or  at  least  the  provisional)  diagnosis,  the  recommendations,  a  record 
of  treatment,  the  results  of  treatment,  and  the  final  disposition  of  the 
case. 

The  question  naturally  arises  whether  it  is  necessary  or 
indeed  desirable  to  make  such  an  exhaustive  investigation 
of  each  case  as  that  contemplated  by  the  above  schema. 

17 


The  answer  is  that  it  is  usually  desirable,  but  not  always 
necessary  or  possible  to  do  so.  Unless  the  clinicist  has  at 
his  command  the  necessary  staff  of  assistants  he  must 
content  himself  with  a  far  less  thorough  investigation.  He 
should,  however,  at  all  times  attempt  to  secure  a  certain 
minimum  of  data  which  bear  significantly  upon  psycho- 
educational  cases.  Such  a  minimum  is  represented,  I 
believe,  by  the  following  abbreviated  record  blank.  It  is 
reproduced  from  the  routine  blanks  which  have  been  in 
constant  use  in  my  clinic  for  several  years. 

FORM  IX 
ABRIDGED  RECORD  BLANK 

Child's  name  (with  street  and  city  address  and  'phone) 
Parents'  names  (with  address  and  'phone,  if  different) 
Referred  by  Brought  by  Date 

Data  secured  from  Recorded  by 

Exact  age:  date  of  birth  Age  in  yrs.  and  mos. 

Place  of  birth  Nationality  of  father  of  mother 

Language  spoken  at  home 

I.  PEDAGOGICAL  RECORD 

School  now  in  All  schools  attended,  in  correct  time 

order,  with  dates 

Age  on  entering  first  school  (including  kindergarten) 

Number  of  years  (or  months)  in  school  Present  grade 

In  what  grade  should  child  be  according  to  age  Years 

retarded  Number  of  years  (or  months)  in  each  grade 

(including  kindergarten) 

Grades  repeated  (indicate  whether  one,  two  or  three  years) 

Will  child  be  promoted  this  year  Attendance 

Greatest  capacities,  abilities  or  talents  shown  in  school  work   (best 

subjects)  Greatest  interests 

Greatest  deficiencies,  worst  faults,  poorest  school  subjects 

Physical,  mental  and  moral  characteristics,  disposition,  deportment 

Other  comments  by  teachers 
School  medical  inspection  record 
School  record  of  brothers  and  sisters 

18 


II.  HOME  AND  ENVIRONMENTAL  CONDITIONS 

Parents  alive  Living  together  Breadwinner 

(who)  Financial  conditions  Home  sanitary, 

well  ventilated,  clean  In  house,  tenement,  shack,  apart- 

ment In  good  or  bad  (shimmy  or  immoral)  neighbor- 

hood Social  or  moral  conditions  in  home 

Home   treatment    (child   neglected,   cruelly   or   kindly   treated,   well 
cared  for)  What  does  child  usually  eat 

What  does  child  drink  Hours  of  retiring  and 

arising  Does  child  keep  bad  company 


III.     CHILD'S  DEVELOPMENTAL  HISTORY 

Birth  conditions:  on  time  premature  (how  much) 

Labor,  how  long  With  instruments  Birth 

injuries  How  nursed  (length) 

Health  as  babe  Infant  and  child  diseases  (state  age, 

severity,  after  effects):  Croup  Whooping  cough 

Chicken-pox  Measles  Diphtheria  Scarlet 

fever  Typhoid  Pneumonia  C.-s.  menin- 

gitis Infant  paralysis  Spasms  (describe) 

Enuresis  Accidents  By  whom  previously  examined 

and  diagnoses  given 

First  teeth,  when  (any  illness)  Fontanel  closed 

First  stood  alone  First  sat  up  First  steps  unsup- 

ported First  walked  unsupported  First  used  single 

words  Short  phrases  or  sentences 

Mental  and  physical  peculiarities  in  infancy  and  childhood  (age 
first  observed):  queer  or  unusual  behavior,  talk  or  ideas;  emotional 
fits  or  outbreaks,  fears,  night  terrors,  destructive,  disobedient, 
vagrancy,  truancy,  veracity,  delinquencies,  bad  sex  habits,  social 
traits,  play  tendencies,  stupid,  sluggish,  quick,  bright 


IV.     HEREDITARY  FACTORS 

Health,  habits,  diseases,  drink,  etc.,  of  father  and  mother  before  and 
during  conception 

Pregnancy  conditions  (overwork,  poor  health,  infection,  drink, 
abuse,  starvation,  etc.) 

Age  of  mother  at  child's  birth  of  father  Parents 

related 

19 


| 

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v  ci 

li 

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Order  of  child's  birth 

Number  of  Sisters 
Number  of  Brothers 

Give  facts  in  regard  to  the  following  defects,  conditions  or  diseases 
found  in  the  child's  brothers,  sisters,  mother,  father,  maternal  and 
paternal  great-grandparents,  grandparents,  aunts,  uncles,  first  and 
second  cousins,  etc.: 


Is 
|.&3 

fis-s 

Nervous 

Mentally 
queer 

% 
fc 

Epileptic 

Insane 

Alcoholic 

Criminal 

Sexually 
immoral. 

Diseases 
(what) 

J3  v 

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QO<! 

"3 

£ 

20 


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